Dr. George's Complete Wellness

Insurance Form

Please complete the patient information (in bold print) areas on this form, using your keyboard. Then print it using the print function of your browser.  You can then sign the form and bring it with you to your first appointment. This form will not be submitted via the Internet, so security is not an issue.

The following questions are necessary so that we may properly file your insurance for you. These questions are taken directly from the insurance form that we must fill out and file for you. Please answer as fully as possible.

The reputation of chiropractic for obtaining "instantaneous" results is excellent - even after other healing methods have failed - but no one should "try" chiropractic care for a few days, hoping to have a miracle performed. We would much rather not have a patient at all than to fail to obtain the maximum results. That is one of the reasons we accept only those patients who will combine forces with us to work as a team to achieve their health goals.

To achieve lasting results spinal misalignments and nerve disturbances must be corrected so Nature can restore normal function to the affected organs and all parts of the body. To make these corrections, REGULAR ADJUSTMENTS and TIME TO HEAL will be necessary.

How quickly your problem responds to our chiropractic care depends on several factors:

As you receive Corrective Chiropractic Care, remember that only Nature heals -and heals only after the causes within the body itself have been corrected. Through the "avenues of the nervous system" she mends broken bones, heals wounds, repairs and strengthens strained and torn ligaments and tendons, relaxes muscles, eases tension, and regulates circulation. In short, when the cause of your condition is removed, healing begins. Nature must have time to effect this healing. Spinal adjusting is similar to adjusting crooked teeth. Both must be done gently and gradually, and in both cases time is required to secure and maintain correction.

When you have completed each recommended series, we re-examine you to determine your progress and actual rate of improvement, and make further recommendations, which might be indicated at that time.

Health Insurance Information "Not A Guarantee of Benefit/Payment."

Verified By:        Spoke To:

Date Verified:   Time: 

Primary or Secondary

Insurance company name: Address to send claims:

Insurance Phone # Fax#:

Policy number:      Group number:

Effective date:

What type of policy does the patient have? PPO  POS  HMO   Managed Care

  Other

Insured's Information if other than patient:

Name of Insured:

Address of insured if different from patient:

Insured's home phone #: Insured's work phone #:

Insured's employer: Relationship to Patient:

Insured's DOB: Insured's SSN:

In Network  Outwork

Does Insurance accept chiropractic assignment? Yes NO

Does the patient need a referral from their PCP? Yes NO

Deductible:     How much has been met? Out of pocket:

Service cap:     Visit Cap:     Life time max:

Patient's co pay/co-insurance pays:%     DME coverage: %

Supply coverage: %     Supplement coverage: %

Exams:%      X-Rays:%     Modalities: %    

Codes 97530 97110     

Is Dr. on their preferred providers list?

If not, how can we get on it?

Is there a protocol to follow?  Yes NO IF YES, PLEASE FAX IT TO: (817)599-0062

Is preauthorization/recertification needed to treat patient?  Yes NO

Definition of Medical Necessity:

Make a copy of patient insurance card and photo on the back of this page.

Insured's or Authorized Person's Signature: I authorize payment of medical benefits to Dr. Chandler George, for the services described on the insurance form. This authorization is to apply to all occasions of service until it is revoked in writing. I agree to pay for services not covered by insurance and understand that I am ultimately responsible for payment in full at this office.

Signed:         Date:

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